SOLVING

PROBLEMS  &  CONCERNS

WITH  THE  NURSING  HOME

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       As your family member’s health care provider, the nursing home has an obligation to meet the medical, environmental, and psychosocial needs of all residents.  You have expectations of them doing what they are supposed to do, how they should do it, and when it should take place. When things do not happen as you feel they must, the resulting concerns have emotional consequences for you and your family. To minimize the worry and frustration, family members can take the organized approach below to minimize the inevitable problems and concerns that flow from the need to nursing home care.




                                                   PAGE CONTENTS

          Working within an unhappy situation.

        ∆  Solve serious problems quickly.

        ∆  Proactive problem solving.

        ∆  Elements of organized problem solving.

        ∆  Understanding the nursing home.

        ∆  Understand the medical condition.

        ∆  Participate in the family council.

        ∆  Build positive relationships with staff.

        ∆  Participate in the care plan process.

        ∆  Take concerns to employees nearest the problem.

        ∆  Use the facility’s grievance process.

        ∆  Take it to the administrator.

        ∆  Involve the Ombudsman.

        ∆  Take your concern to the owner.

        ∆  Report concerns to regulatory agencies.

        ∆  Taking legal action.

        ∆  Stay with the goals.




∆  Working within an unhappy situation.

    The circumstances that brought your family member to need this health care process are beyond your control.  Your life and the life of your family member have changed dramatically and will probably never be the same again.  There are financial worries and concern for the care and emotional state of other family members.  New responsibilities have been thrust upon you with the possibility of even more being added and you cannot see an end to these situations. In these undesirable circumstances, you need things to work as you feel they should. Calmness is almost impossible. The emotional pressure is great and your temper grows shorter with each new undesirable situation.

   

    When anger develops from inadequate care of your loved one, the important question is whether it is more important express your displeasure and frustration to the facility staff or resolve your concerns for the care being delivered.    You are unlikely to do both.  On top of the other challenges, you are confronted with getting the best results by focusing energy on positive solutions. This page is about resolving problems in highly emotional circumstances with people you may feel have failed you and your family member.


    It is important that you put your concern in writing before or just after bring it to the attention of the appropriate staff member.  You can use the grievance form each facility should have available to the public or may find you can express your concern better in your own style. A written description of your complaint allows staff to share exactly what you have expressed and leaves a record of having informed them of the concern.     Include your desire for a written follow-up and ask for a deadline for their response in your written complaint.


    If the problem is one that requires quick staff intervention to prevent or respond to harm of a resident, tell the staff immediately of the danger but follow up with a written description of the serious situation and your expectation for preventative measures to be taken for the future.


  Solve serious problems quickly.

    The majority of material presented here is based upon concerns that have a low risk of harm to the resident and for building a long term problem solving process with the facility.  How fast these approaches should be applied must be determined by the severity of problems faced and the time available for you to put the processes into action.


   If the situation leaves the resident open to some form of harm if not immediately addressed, the concern should be voiced without hesitation immediately to the unit nurse.  The reporting person should behave with the expectation of an prompt response from the nurse, director of nursing, social worker, administrator, or other supervisory person who can provide the necessary action to assure the safety of that resident and any others who may be affected by the same situation.


    It is best to continue pressing the matter up the staff chain of command until the reporting person is satisfied the resident is out of potential harm’s way and appropriate action has been taken to prevent the situation from reoccurring.  As a last resort consult the Ombudsman to identify the appropriate regulatory agency and file an immediate complaint with them.


    No matter the severity of the problem, in all cases it is important to report a concern as soon as possible after it happens along with the details of the matter to the unit nurse.



   For more information on the services of the Ombudsman, see the page Ombudsman’s Help in the Nursing Home at this website by clicking HERE.



  ∆  Proactive problem solving.

    At the first sign of a concern, it is best to be able to freely discuss it with the facility staff.  Friendly, open communication built upon good relationships with nursing aides, unit supervisors, the director of nursing, social worker, administrator, or other employee with responsibility to the area of concern can keep small clinical care and environmental problems from becoming serious.

                        

    The overall approach to working well with the nursing home is to be proactive.  Get ahead of the situation and lay groundwork for future solutions to problems that will inevitably arise. That is, you take the lead in establishing relationships and processes that support problem solving before they are needed.  Instead of being the angry family member who reacts to care concerns, your goal should be to develop such a strong respectful relationship with staff so that they see you as someone they do not want to disappoint with poor care of your family member.  For this to happen there must be never ending effort on your part to establish such relationships and the results can be much more satisfying than those from an explosion of anger.


    To become a person staff respects and responds to you must be knowledgable of nursing home processes, be consistent in your actions and words, avoid unsubstantiated accusations, invest time and effort in building relationships, be firm but fair, and stay with it until a solution to any failure of the facility to meet the required standards of care is resolved.


  ∆  Elements of organized problem solving.

    Solving care concerns rather than venting anger and frustration requires an investment of time and follow through.  The elements of such problem solving involve the following responsibilities and actions.

  1. 1.Invest time in learning how a nursing home operates and the limits of the facility’s care responsibilities.

  2. 2.Understand the nature; physical, emotional, and psychological effects; effective medical treatments; and potential for recovery for the medical condition(s) of your family member.

  3. 3.Participate in the family council if there is one.

  4. 4.Build positive relationships with nursing home staff.

  5. 5.Participate in the care plan process.

  6. 6.Take your concerns to the nursing home staff nearest the source of your concerns.

  7. 7.Use the facility’s grievance process.

  8. 8.Take it to the administrator.

  9. 9.Involve the Ombudsman as a mediator.

  10. 10.Identify the owner or person the administrator reports to and communicate your concerns to them.

11. Take it to the appropriate regulatory agency.


  ∆  Understanding the nursing home.

    Understanding how a nursing home operates and the constraints, procedures, and responsibilities that dictate how they must function provides a foundation for communicating your concerns to facility staff.  Some frustration with nursing home care is the result of unrealistic expectations or a misunderstanding of what a long term care facility is supposed to provide in the form of care, response to family preferences, and personal services and amenities.  Knowing how a nursing home is supposed to function puts a family member in position to ask for and expect care improvement and problem corrections the facility staff can actually provide.



   For more information on understanding how nursing homes function, see the website page How Nursing Homes Operate by clicking HERE.



  ∆  Understand the medical condition.

    Today’s medical advances can lead to higher expectations for improvement or recovery from illnesses or that the effectiveness of today’s treatments should maintain and extend the life of seriously ill family members despite their condition.  Before finding fault with the facility’s care processes, family members should become aware of the realistic outcomes and quality of life resulting from the medical care available for their resident’s specific diagnoses. Understand the nature; physical, emotional, and psychological effects; effective medical treatments; and potential for recovery for the medical condition(s) of your family member.


    It is natural to hope for and expect improvement in the health of your family member or at the least, for their condition to remain at the level of their admission.  Understanding the realistic expected progress of each diagnosis and effect it has on other body systems allows the concerned family member to accept those symptoms that cannot be improved and identify areas that may respond to better care.



   For information on diagnosis, interventions, treatments and expected outcomes of specific medical conditions see the website of the Agency for Healthcare Research and Quality at: 

http://www.guideline.gov/browse/index.aspx?alpha=A



  ∆  Participate in the family council.

    When a problem arises or is ongoing, it most likely affects other families and residents as well.  The family council is the best way to discover if that is so and how other families have been pursuing solutions to the problem.


   The family council should serve as advocates for resident rights, care and personal needs, and quality of care concerns.  As a group, they can support facility management and staff to create the most positive long term care environment possible.  A successful council is involved with families, residents, staff, and management in a manner conducive to effective communication, cooperation, and mutual respect.  They are the most helpful when the focus is on finding solutions to problems or identifying needed improvements that will enrich the lives of residents.


    Work through the family council to support an attitude of cooperation between facility management and resident family members that provides an ongoing system of addressing concerns and problems in resident care and daily living.  Solving problems can be more effective when working as an organized group.



   For information on establishing and participating in a family council, see the website page Family Council in the Nursing Home by clicking HERE.



  ∆  Build positive relationships with staff.


    It is a human basic that if the staff only hears from family members when there is a problem, they will tend to minimize their time with the resident to avoid the possibility of criticism for any care they provide.  Employees with positive relationships with family members are more likely to work with the family to see that the resident gets good care.  They will feel free to discuss problems they see and suggest solutions without the fear of being chastised.


    Take time to learn the names of staff and understand their care responsibilities and professional limitations.  Find reasons to praise and thank them for the work they do.  A strong positive relationship can develop a need on their part to please and not disappoint you.  Within strong personal relationships, they will listen and respond when you fairly and evenly point out care deficiencies to them.


    It is understandable that staff may feel overworked and operate under stressful circumstances, but expectations for good care should not be lowered.  Appreciate the conditions under which they work, but don’t let that prevent your being assertive, confident, and respectful in pursuing solutions to your concerns.


  ∆  Participate in the care plan process.

    The nursing home is required to provide opportunities to the resident and any interested party approved by the resident to voice concerns in periodic care plan conferences.  The resulting care plan should reflect the findings of the required assessment process but can also incorporate care processes to address concerns of family members.


   There are limits to incorporating family member’s desired treatments into the care process.  The regulations governing Medicare/Medicaid certified nursing homes affirm the resident’s right to refuse recommended treatments or to select among treatment options before the care plan is instituted. Those regulations do not create the right for a resident, legal surrogate, or representative to demand that the facility use specific medical intervention or treatment that the facility deems inappropriate.  Statutory requirements hold the facility ultimately accountable for the resident’s care and safety, including clinical decisions.


    Although the care plan team tends to meet at regularly scheduled times, they should be able to modify that to meet at times convenient to family members.


    The planning meeting is an excellent forum for letting your concerns be known, so work with the staff to make the conference work for you.  These conferences are held at least quarterly but do not hesitate to request such a meeting sooner if you feel it is needed.  Care plans can be updated anytime there is a significant change in condition or newly recognized care need to be addressed.


    Meet the agreed upon schedule and arrive well prepared to clearly address your concerns.  Define the results your seeking, make a list of your questions so you can clearly state them or even present them in writing, be prepared to explain why you are concerned for each point you present, and have possible solutions to propose.


    With the ultimate responsibility for the resident’s care and safety falling on the nursing home, it is best to save your solutions until you hear the facility’s proposed response to your concerns.  They must fit their actions within the regulations under which they operate and within their broad experience.  They may have better solutions than yours.  If their approach is unsatisfactory, then present your solution.



   See the page Care Plans in the Nursing Home for more information on the care planning process by clicking HERE.



  ∆  Take concerns to employees nearest the problem.

   Take the problem to the staff member most directly involved immediately or shortly after you become aware of the situation.  Care givers cannot know of your concerns if you don’t tell them.  The staff member nearest the problem should be the one most likely to resolve the situation quickly and simply.


    If frontline staff does not respond or indicate they don’t have the authority to address the problem, move on the next higher level in the nursing home’s chain of command.  Keep moving up to the next supervisory level if it becomes obvious nothing will be done by the persons you are currently working with.  When approaching anyone on staff, take the time to think your report through to provide the most factual account possible of the matter.


  ∆  Use the facility’s grievance process.

    The facility should have a policy and process for receiving and responding to formal expressions of a complaint or grievance.  If working with the health care staff does not achieve results, find out what the formal grievance process is and use it.


    Often a family member will introduce a statement of concern with, “I hate to complain but ...”  If they do not take the time to fully understand their matters of concern and treat the grievance as a serious statement of fact, then perhaps the family member is just complaining. Presenting the grievance on a form that tells facility management the who, what, where, when, and how of the situation takes some work but clearly expressing your family member’s care needs should be worth the effort.


    Putting the matter into writing requires a different approach than verbally stating your concern.  When telling someone of the matter, it is a one to one process with opportunities to explain and clarify if the other party does not fully understand.  Utilizing a written grievance process means that what is said on paper stands alone without the opportunity for you to immediately respond to questions.  It may also be shared with any number of people and become a permanent record of the situation. To be effective, the written communication should be as specific and detailed in describing the concerns.


    An example would be, “Mrs. Jane Doe, diagnosed as a diabetic, has a physician’s order for a diabetic diet and Medicare/Medicaid dietary regulations call for a resident to be served the diet ordered by her physician.  Mrs. Doe has received the regular diet for the last three days.  Each time the wrong diet was discovered by family members, the error was reported to the food services department director. Today the wrong diet was again delivered to Mrs. Doe and discovered by myself.  The continuing diet error threatens the health of Mrs. Doe because she lacks the judgment to distinguish between the right and wrong diet, always eating the meal presented to her.”


    Ask the facility to tell you how they are going to meet the three most important responses to care concerns, which are:

  1. 1.How corrective action has been or will be accomplished for the resident.

  2. 2.What measures have or will be put into place or changes made to ensure that the deficient practice will not recur.

  3. 3.How the facility will monitor the corrective actions to ensure the deficient practice has been corrected and will not recur.


    Before writing your grievance, use this website and resource links to research the regulations, ask the facility to show you their policy and procedure on the topic, check with the nursing staff to see if or how the area of concern is addressed in the care plan, and talk to members of the family council to see if they have seen the same problems and how their grievances were responded to.


    Although this may sound like a complicated process rather than simply saying, “Mother is not getting the right diet.”, it presents your concern in a form similar to the annual survey, a format facility management is used to responding to and shows you are not complaining, but presenting facts and asking for facts in return.


    Not that it will or should, but the matter you are reporting could ultimately lead to sanctions against the facility from Medicare/Medicaid or even show up in court.  Treat a written grievance as if regulators, lawyers, or the media will someday be putting it into the public record.  State supportable facts, not personal opinions or negative characterizations of the facility or staff.


  ∆  Take it to the administrator.

    If taking your concerns to the staff nearest the problem, then to their supervisors, and then putting it into writing as
a formal grievance has not worked, talk to the administrator.  The administrator has the final responsibility for whatever takes place in the nursing home.  His or her position and responsibilities are clearly defined in Medicare/Medicaid regulations and state law.


    Make an appointment rather than catching the administrator in the hallway or dropping by the office.  Come prepared with your written grievance and any additional happenings since the grievance was submitted.


    After the meeting, make detailed notes of what was said and agreed upon.  Provide a copy of the meeting notes with the administrator so he or she will know what you expect to be acted upon and what response you were led to hope for from the meeting.   Writing your version of the meeting is a good tactic because it will naturally be biased to your point of view.  If the administrator does not take issue with the summary, then you have their unstated agreement with your version.


  ∆  Involve the Ombudsman.

        If a meeting with the administrator does not go well, an outside mediator may be called for.  That’s the time to bring the local LTC Ombudsman into the situation to serve as a neutral outsider representing the resident and to arbitrate the differences between you and the administrator.



   For more information on the Long Term Care Ombudsman, go to the Ombudsman’s Help in the Nursing Home section of this website by clicking HERE.



  ∆  Take your concern to the owner.

       If all efforts to this point fail, identify the person the administrator reports to and communicate your concerns to them.  The LTC Ombudsman can help you identify that person.  The owner, corporate regional director, or other person to whom the administrator reports should be given a chance to provide a positive response before going to the regulatory agencies with your concern.


        Write a letter to administrator’s superior with a copy to the administrator.  Include a copy of the submitted grievance and detail all your other efforts for satisfaction to date in that letter.   Sending a copy to the administrator is important because the goal is resolving the care issue, not ambushing him or her.  Think for the long term.  Even if you feel the administrator is not fulfilling his or her responsibilities, you will most likely have to continue working with that person on future situations.  Seek compliance with care requirements not a new enemy.


  ∆  Report concerns to regulatory agencies.

    Do not hesitate to take a complaint outside the facility if working with the nursing home is not getting adequate response to your concerns.  Your purpose is not to hurt the nursing home or the employees, but to obtain the good care that is the basic right of all residents.


    The final arbiter for unresolved care concerns would be the appropriate regulatory agency.  Consult with the LTC Ombudsman to determine the most likely agency to consult.  The state survey agency, adult protective services, local social services agency, or agency on aging each have varying responsibilities that may apply to your concerns.  Get help to identify the appropriate agency for assistance in resolving the problem.


  ∆  Taking legal action.

    When things go so far as contacting regulatory agencies, an attorney has probably been considered. An elder law attorney can be helpful in understanding nursing home laws and regulations. Litigation can be appropriate when a resident has been harmed by a failure of the facility to meet care standards and protect the resident.


    When considering having an attorney resolve your concern with the facility or filing a lawsuit, be sure such an approach is justified before taking that step.  Experience has shown that attorneys may take such cases on what could be called a threatening letter or exploratory basis.  They hope a letter threatening legal action will scare the desired results out of the facility or, as they seek information from the nursing home to explore the situation, they learn the circumstances are very different in terms of the law than what was described to them by the client.


    With the public responding to the heavy advertising by nursing home lawyers, most administrators have been contacted by the attorneys of angry family members who have not gone through the steps suggested on this page. They know how to respond to those legal threats that are without merit and probably have their corporate attorney on speed dial.


    Don’t hesitate to take legal action if it is justified but remember, the nursing home’s law firm will probably be bigger than your law firm, their law firm will probably have more experience in such cases than your law firm, and the facility has liability insurance to cover the cost of much of their legal defense.


    There are circumstances justifying legal action but be sure the matter has reached that point, otherwise such threats and communications from attorneys may just harden the relationship between the family and facility management.


  ∆  Stay with the goals.

   The goals of nursing home services, as described in federal regulations, is to care for the residents in such a manner and environment as will promote maintenance or enhancement of the quality of life of each resident and provide services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident in accordance with a written plan of care.


    Nursing homes can fail to meet those goals leading family members to express their concern.  Taking those concerns to the nursing facility can be an awkward and emotional undertaking but using the suggestions on this page can increase the probability of successfully keeping the facility focused on good care and regulatory compliance.


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